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Medicine and Social Justice will have periodic postings of my comments on issues related to, well, Medicine, and Social Justice, and Medicine and Social Justice. It will also look at Health, Workforce, health systems, and some national and global priorities

Saturday, September 7, 2013

President Bush's stent: inappropriate screening and care for the rich, nothing for the poor

One of the recurrent themes of this blog has been the
importance of everyone having access to necessary medical care, and how the US
compares poorly to other developed countries in that it does not cover everyone. Another recurrent
theme has been that many medical procedures are unnecessary, sometimes even
harmful, but are nonetheless provided to people who have the money or insurance
to pay for them. This is not to say that greed is always the motivator; there
is a powerful, if often incorrect, belief that to do something is better than to do nothing.

In this context, it is interesting to read “President
Bush’s unnecessary heart surgery”, a Washington
Post “Viewpoint” by Vinay Prasad and Adam Cifu published August 9, 2013. As
part of his “annual physical”, the former President (who is “…widely
regarded as a model of physical fitness”), received, in addition to (presumably)
the screening tests and immunizations recommended by the evidence, a cardiac
stress test. Discovering an abnormality on that test led to his having a CT
angiogram and finally placement of a cardiac stent.

One interpretation of this story might be “he’s lucky they
did the test; they found something wrong and fixed it”. I’m afraid, along with
Prasad and Cifu, that this might be the lesson taken from it by many people,
and the result could be more people requesting such a test because, “hey, they
found something wrong with President Bush – could I also have such a problem?” This would be unfortunate, because it
is incorrect. President Bush – based on the information provided – should not
have had the stress test and not have had the stent placed.

The key point is in understanding that he was (by all
reports) asymptomatic. “Before he
underwent his annual physical, Mr. Bush reportedly had no symptoms. Quite the
opposite: His exercise tolerance was astonishing for his age, 67. He rode more
than 30 miles in the heat on a bike ride for veterans injured in the wars in
Iraq and Afghanistan.” While the definition of screening tests is that they
are done on asymptomatic people, there are a number of criteria that have to
also be present, among them that the test should detect a condition before it
is symptomatic, and there should be an intervention that will prevent
progression if disease is discovered. So, isn’t that true in this case? He did
have the disease, a narrowing in one of his coronary arteries, right? So isn’t
it good that it was discovered.

As Prasad and Cifu discuss,
however, there is no evidence that stenting a coronary artery prolongs
life. “It is worth noting that at least two large randomized trials
show that stenting these sorts of lesions does not improve survival.” Even for higher risk patients than Mr.
Bush, survival is not increased. However, if people have symptoms of chest pain
that appears cardiac in origin, for whom stress testing may be indicated (not a
screening test now; they are symptomatic),
treatment by angioplasty, stenting, or even bypass surgery can ease or relieve
the pain. That is a good thing. But for Mr. Bush, who had no pain, there can,
by definition, be no pain relief. There was
some additional risk, however; in addition to the inherent low risk of
doing the procedure (such as bleeding and stroke, and even, rarely, death), he now has to take
anti-platelet drugs, which also confer some risk. And a stent only holds open
the spot it is in; it does not prevent progression of coronary artery disease
elsewhere.

The larger issue
of the “annual physical” (which I have addressed previously in “The
"Annual Physical": Screening, equity, and evidence”, July 4, 2012, citing Elizabeth Rosenthal’s NY Times article “Let’s (not) get
physicals”) was again the subject of a popular article, “The case against the annual checkup” by Brian Palmer on Slate.com on August
20, 2013, which states: “There are two
kinds of arguments against the adult annual health checkup. The first has to do
with the health care system overall, and the second has to do with you
personally.”Palmer
does add that

“It’s important to separate preventive
care from annual checkups. Only one-half of annual checkups actually include a
preventive health procedure such as a mammogram, cholesterol testing, or a
check for prostate cancer. (Annual gynecological visits are excluded from these
numbers, although the evidence supporting those is not particularly
overwhelming either.) More importantly, only 20 percent of the preventive
health services provided in the United States are delivered at annual
checkups.”

He has a pretty
good point, although he includes prostate cancer screening, which is not
recommended or beneficial, in his list, something Prasad and Cifu do not. But I
would take issue with his suggestion that you only visit the doctor when you
are sick, which is in fact when doctors tend to work in the preventive services
the other 80% of the time.

There are a
couple of reasons for this, but the main one is that there are a lot of people
(even older people at higher risk) who do not get sick, or at least sick enough
to decide to come to the doctor, or at least sick enough to decide to take off
from work and maybe lose income to come to the doctor. And they could benefit
from preventive care as well. The list of preventive services changes from time
to time, which it should as new evidence emerges, but includes immunizations, screening, and education. The list of conditions for
which screening is effective and
recommended by the evidence is relatively short (despite our natural desire to
have more, more effective, tests) and does not include prostate cancer or
ovarian cancer (thus, no reason for an asymptomatic woman to have a “routine”
bimanual pelvic exam), but does include Pap smear for cervical cancer,
colorectal cancer screening (which can be done with colonoscopy or regular stool
screening for occult blood), bone density screening for certain age groups, and
mammography. There are also recommended screening for other conditions:
hyperlipidemia (mainly cholesterol), abdominal aortic aneurysm (once, in men
over 60 who have smoked), HIV and Hepatitis C, as well as some screens for
people who are themselves asymptomatic but whose family history places them at
higher risk for a condition (e.g., diabetes). (See the
Guide to Preventive Services 2012, Recommendations of the US Preventive
Services Task Force, on the website of the Agency for
Healthcare Research and Policy.)

Immunizations include not only annual influenza shots, but also
less-frequent pneumococcal vaccine and tetanus/diphtheria/pertussis boosters, which
are often not up-to-date in adults.
Education may be the most important: counseling on diet, exercise, smoking,
alcohol, drugs, and risk behaviors, as well as identifying victims of violence
(domestic or otherwise) should not wait until these conditions have resulted in
symptomatic disease.

Perhaps these
preventive services should not be “annual”; there is no magic to this number,
but it was chosen because it is easy to remember. Certainly many of these
preventive services (now including Pap smears, bone density and mammograms) are
recommended less frequently than yearly. Perhaps they can be as well delivered
by other health professionals as by physicians. But there is benefit to
preventive care even for asymptomatic people, and not the least is noted by
Palmer: “They build relationships between
doctor and patient, and open lines of communication are important in medicine.” Yes, there are certainly many risks,
which I have often pointed out, to over-testing and over-medicalization. But
there are also risks to not having preventive care. And, of course, the key
point here is equity: those most at risk of “too much” care and too many
interventions are the more well-to-do, well-educated, and well-insured. Those
most at risk of too little care, too little screening and immunization and
education about how to reduce their risks and early identification of disease
are the poorer, less educated, and uninsured.

The fact is that
health care, like most things in our society, is very different for different
socioeconomic classes. Cautioning against overuse by the privileged is one
thing; being sure that this does not bleed into justifications for limiting
access to necessary care for the less privileged is quite another.